In response to PAR-10-040, the overarching goal of the proposed R21 study is to develop a suite of adherence measures that can be used by clinicians, supervisors, quality improvement professionals, and implementation scientists to monitor and support the implementation of evidence-based child and family cognitive-behavioral therapy (CBT) within community-based clinical practice. Despite the success of CBT for child emotional and behavioral problems in controlled trials, CBT is still used infrequently and incompletely in clinical practice. Implementation scientists are actively investigating ways to improve uptake and use, but there is currently no practicable means of evaluating whether such efforts to influence clinicians'in-session behavior have actually succeeded. The inability to monitor fidelity quickly and cost-effectively also represents a major roadblock to individual clinicians, supervisors, and agencies striving to implement CBT with their clients. Current methods of examining treatment fidelity rely on time-consuming, resource-intensive, direct observation coding of taped sessions. The expense and complexity of these procedures make them impractical beyond small-scale or highly- funded clinical trials. Large-scale training and implementation efforts require valid measurement of CBT fidelity that is feasible across a wide range of service settings and budgets. The proposed research involves working with CBT experts, clinician stakeholders, as well as consumers of services and their caregivers, to develop and pilot test clinician, caregiver and youth report versions of a CBT adherence measure (CBTAM). In keeping with the R21 mechanism, the focus is on demonstrating the feasibility of using such indirect measures, in place of trained observer coding, to assess adherence to CBT for child emotional and behavioral problems within community- based clinical practice. For CBTAM to meet this measurement need in implementation research, it must demonstrate content validity, accuracy, and clinical utility. The proposed research will proceed through three phases to (a) establish and refine content coverage, item wording, response format, scale scoring, and administration procedures and to (b) examine evidence for content validity, accuracy and clinical utility of each reporter's CBTAM. Phase I involves initial item and scale development through content coding of CBT manuals, consensus with CBT experts, and cognitive interviewing with clinicians, caregivers and youths. In Phase II, weekly and monthly clinician, caregiver and youth reports on the CBTAM will be compared with session-by-session observational coding of CBT adherence to establish accuracy within a university-based research and training clinic. In Phase III, the refined CBTAM measure and administration protocol will be tested with child clinicians and their clients in the Missouri Therapy Network, a practice-based research network of clinicians spread across urban, suburban and rural clinical settings. The resulting adherence measure can be used to estimate baseline use of CBT, to evaluate the success of clinician training and other implementation efforts, and to support provider efforts to achieve fidelity to CBT, all within community-based clinical practice.

Public Health Relevance

Each year, about 6% of America's children receive MH care, at an annual cost of more than $11 billion. In order for these children to benefit from the scientific advances made in treatment efficacy and effectiveness research, it is essential that scientifically supported treatments be implemented in everyday MH practice. This research directly addresses this public health imperative by providing a valid, clinically useful suite of measures that MH providers, quality improvement professionals and implementation researchers can use to monitor and promote the accurate implementation of one such treatment, cognitive-behavioral therapy, within MH practice.